ST WINIFRED’S CATHOLIC PRIMARY SCHOOL – NURSERY

INFORMATION FORM  

 

Please print clearly and complete all boxes

 

 

Surname

[as shown on birth certificate]:                        

 
 

Forenames

[as shown on birth certificate]:

 
 

Usually known as:

 
 

Date of Birth:

 

Gender: 

 

Nationality:

 

Country of Birth:

 

Mother’s Surname:

 

Forenames:

 

Father’s Surname:

 

Forenames:

 

Home Address:

 

Home Telephone No:

 

Email:

 

Normal Mode of Travel:

 

Resident in London Borough of:

 

 

IN THE EVENT OF ILLNESS/EMERGENCY THE FOLLOWING TELEPHONE NUMBERS WILL BE USED.  WE WILL AUTOMATICALLY CONTACT PARENTS FIRST, UNLESS INSTRUCTED OTHERWISE.

 

 

Mother’s Contact Numbers:

 

    

 

Home:   …………………………………………………………….    

 

Mob:     …………………………………………………………….

 

Work:    ……………………………………………………………

 

Father’s Contact Details:

              

              

 

Address [if different from above]:

 

 

 

Home:   …………………………………………………………..    

 

Mob:     …………………………………………………………..

 

Work:    ………………………………………………………….

 

Email:    ………………………………………………………….

 

 

 

Other Contact Numbers:

 

 

Name:  …………………………………..                         [Relationship to child:                               ]

                               

Phone No: ……………………………………

 

 

Name:  …………………………………                           [Relationship to child:                                ]

 

Phone No: …………………………………….

 

 

Name:  …………………………………                           [Relationship to child:                                ]

 

Phone No: ………………………………………

 

Home Circumstances:

 

2 parents …….   1 parent …….   1 parent/1 step parent …….  Looked after/Adopted …….

 

 

Family Doctor’s Name & Address:

 

 
 

Medical Conditions or Allergies [e.g. asthma; allergy to penicillin; nut allergy]:

 
 

Medication if Necessary:

 
 

Medication Required in School:

 
 

Any Other Medical/Dietary Information:

 
 

Name & Address of Previous Nursery or School:

 

 

 

Date started …………………………           Date left …………………………….

 

Religion:

 

 

Roman Catholic                    ¨

Church of England               ¨

Christian                                ¨

Orthodox                               ¨

Muslim                                   ¨

Hindu                                     ¨

Other [please state]            ¨

No Religion                            ¨

Refused                                 ¨

the following information will be used by the local education authority to assess the school for additional funds for teaching purposes
Main language spoken at home:
 
Any other language spoken at home:
 
 

Date of Entry into the UK, if applicable:

 
 

Date of First Exposure to English, if applicable:

 

 

 

Signature of Parent/Carer ………………………………………………………………………             Date …………………………………………………………